Cystic Fibrosis Nursing Care Plan

Ineffective airway clearance related to thick mucus secretions and effort and a lot of bad cough.

Goal: Not experiencing aspiration.

Auscultation of breath sounds. Note the example of wheezing breath sounds, crackles, rhonchi.
- Rationale: Some degree of spasm of the bronchial obstruction with airway obstruction and may / not indicated the presence of abnormal breath sounds or crackles eg absence of breath sounds.
Perform physiotherapy to issue secret and give the patient a comfortable position, eg, elevation of the head of the bed, sitting on the back of the bed (position semi-Fowler / Fowler).
- Rationale: head of bed elevation facilitate respiratory function using gravity.
Assist clients to dilute sputum, with the collaboration expectorant administration to improve airway clearance.
- Rationale: Giving expectorants may help thin the secret, that secret is more easily removed.
Provide nebulizer with a solution and in accordance with the right tools.
- Rationale: Nebulization can help spending viscous secretions.
Observations clients closely after aerosol therapy and chest physiotherapy to preventaspiration due to many sputum suddenly become watery.
- Rationale: To prevent aspiration.
Provide postural drainage (adjust the area where there is a buildup of mucus) as prescribed to reduce the viscosity of mucus.
- Rationale: Postural drainage aids in the excretion of mucus is thick.

Goal: Maintaining adequate oxygenation or ventilation.

Maintain a patent airway.
- Rationale: Preventing complications of respiratory failure.
Position the patient to obtain maximum efficiency ventilators, such as a high Fowler’s position or sitting, leaning forward.
- Rationale: Position Fowler / semi-Fowler can facilitate respiratory function and can reduce airway collapse, dyspnoea, and breath work by using gravity.
Monitor vital signs, arterial blood gases (ABGs), and pulse oximetry to detect / prevent hypoxemia.
- Rationale: increased PaCO2 indicates impending respiratory failure during asthmatic. Tachycardia, dysrhythmias, and changes in BP may indicate systemic hypoxemia effects on cardiac function.
Provide supplemental oxygen according to the provisions / requirements. Monitor patients closely for carbon dioxide narcosis due to oxygen is danger of oxygen therapy in patients with chronic lung disease.
- Rationale: Occurrence / respiratory failure that would require effort dating lifesaving action. Supplemental oxygen administration can fix / prevent worsening hypoxia.
Motivation exercise appropriate physical condition of the patient.
- Rationale: Physical exercise is often effective to clear accumulated lung secretions and to improve endurance exercise capacity before experiencing dyspnea

Goal:

Patients showed an effective respiratory frequency with the frequency and depth within the normal range and lungs clear / clean.
Patients free of dyspnea, cyanosis, or other signs of respiratory distress.

Provide position Fowler or semi-Fowler.
- Rationale: Position Fowler / semi-Fowler enables lung expansion and ease breathing. Changing position and ambulation improve air charging different lung segments which improves gas diffusion.
Teach deep breathing techniques, and or lip breathing or diaphragmatic breathingabdominal exercises when indicated and effective cough.
- Rationale: to help spending sputum.
Observation vital signs (RR or frequency per minute).
- Rationale: Tachycardia, dysrhythmias, and changes in BP may indicate the effect of systemic hypoxemia pad cardiac function.